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Difficulty: Very hardPhysiological Adaptation

A practical nurse is changing the abdominal dressing of a client who is four days postoperative from an exploratory laparotomy. When the client forcefully coughs, the nurse observes internal organs protruding through the opened incision line. In which sequential order should the practical nurse prioritize the following interventions? Arrange the actions from first to last.

  1. 1Stay with the client and activate the emergency call light to request assistance and sterile supplies.
  2. 2Position the client in a low-Fowler's position with the hips and knees flexed.
  3. 3Cover the protruding internal organs with sterile dressings thoroughly moistened with sterile normal saline.
  4. 4Obtain a complete set of vital signs to evaluate for indications of severe pain or hypovolemic shock.
  5. 5Ensure the client remains on strict nothing by mouth (NPO) status in preparation for emergency surgery.

Answer

The correct sequence of actions is to first call for help while staying with the client, position the client to reduce abdominal tension, cover the exposed organs with moist sterile dressings, assess vital signs for shock, and maintain NPO status for emergency surgery.
In an acute evisceration, the practical nurse must prioritize actions that protect the client and the exposed organs while expediting emergency medical intervention. First, the nurse must never leave the client; activating the emergency system brings necessary personnel and sterile supplies to the bedside. Next, positioning the client in a low-Fowler's position with flexed knees is a critical mechanical intervention that instantly reduces intra-abdominal pressure and prevents further protrusion of the bowel. Once sterile supplies are available, the nurse must cover the exposed viscera with sterile, saline-moistened dressings to prevent tissue necrosis and severe infection. After the site is physically protected, obtaining vital signs is essential to monitor for hypovolemic shock, a major systemic complication of evisceration. Finally, because evisceration requires immediate operative repair, the nurse must ensure the client is kept strictly NPO to prevent aspiration during anesthesia.

Step-by-Step Solution

1
Activate the emergency response while staying with the client.
Ensures the client remains safe while necessary sterile supplies and personnel are brought to the bedside.
The practical nurse must not leave an unstable client; leaving could lead to further injury or severe complications.
2
Place the client in a low-Fowler's position with knees flexed.
Minimizes intra-abdominal pressure.
Relieving tension on the abdominal wall physically prevents further evisceration of internal organs.
3
Apply sterile, saline-moistened dressings over the evisceration.
Protects the exposed bowel from the external environment.
Exposed viscera are highly susceptible to drying and infection, which can cause tissue necrosis. Sterile normal saline maintains moisture safely.
4
Assess and document the client's vital signs.
Provides baseline hemodynamic data.
Evisceration can trigger a massive stress response and fluid shifts, leading to hypovolemic shock. Tachycardia and hypotension require immediate medical intervention.
5
Reinforce NPO status and prepare for surgery.
Prevents aspiration during future anesthesia.
Wound evisceration is a surgical emergency requiring operative closure. Maintaining strict NPO status is critical for safe intubation.

Key Concept

Wound Evisceration Emergency Management
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Topics

Physiological Adaptation

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